A couple of years ago, Jennifer Clark, a 40-year-old teacher and clinical counseling graduate student in Colorado, started waking up soaked in sweat a few nights a week. Her once-healthy libido and mood took a major dip, she was gaining weight, and, eventually, her periods got closer together — sometimes they’d come twice in a month. Clark suspected perimenopause, but multiple OB/GYNs gave her the same advice: Eat healthier, exercise more and sleep with a fan on. “They made me feel like it was all in my head,” she said.
Amid ongoing celebrity conversation about menopause — Michelle Obama, Oprah Winfrey and Naomi Watts have opened up about their experiences in recent years — this hormonal transition has become a hot topic online and in health care.
Kristen Venuti, an OB/GYN at Northwestern Medicine, said she has recently noticed an uptick in the number of her patients asking whether their symptoms could be a sign. “When I started my practice six years ago, I probably had one person a week bringing up perimenopause. Now several people bring it up a day.”
Still, like Clark experienced, finding relief isn’t easy. With a barrage of possible symptoms and no concrete way to know whether you’re officially in perimenopause, many women are left wondering what’s going on in their bodies and what they can do to feel better.
Understanding this hormonal milestone, experts said, can help you advocate for yourself and manage bothersome symptoms. Here’s what OB/GYNs want you to know about perimenopause and how to get support.
Estrogen and progesterone are the main drivers
Perimenopause is the several-year period leading up to menopause, which essentially starts one year after a person’s last menstrual period. During that time, there are fluctuations in the sex hormones estrogen and progesterone, which can cause physical and emotional symptoms, said Anna Barbieri, an OB/GYN with Mount Sinai Hospital in New York.
Before menopause, the brain alerts the ovaries each month that it’s time to ovulate. With age, the ovaries don’t respond as readily to this messaging, said Karen Adams, clinical professor of OB/GYN at Stanford Health Care. This results in inconsistent ovulation and random dips and surges in estrogen — well beyond the predictable fluctuations that occur throughout a typical menstrual cycle. Irregular ovulation ultimately throws off progesterone production, too.
“While hormonal changes drive perimenopause, there are other changes happening, including the effect of these changes on neurotransmitters, the cardiovascular system, metabolism and more,” Barbieri said. “These hormones don’t exist in a vacuum. They’re intimately related to other processes in the body.”
This is why perimenopause is linked to a higher risk of cardiovascular disease, bone loss and even depression.
It can last for months or years
Like puberty, perimenopause is a transition, not a particular point in time. Typically, the process starts in a person’s late 30s to mid-40s, Barbieri said. Genetics play a role in timing. If your mother experienced perimenopause symptoms starting at around age 40, you may, too.
Studies show the median time span for perimenopause is four years, though it can last much shorter or longer. According to Barbieri, in some cases, symptoms could last for as long as a decade before a person’s period finally stops. Menopause is the year after the last period, and the time after that is considered postmenopause.
Symptoms are wide-ranging, but a few are very common
A hallmark of perimenopause is changes to the menstrual cycle, Adams said. In the first few years of this time, periods tend to get closer together. If your cycle has always been about 30 days, it may shorten to every three weeks (often, with worsening PMS symptoms). You may also skip your period some months.
Hot flashes and night sweats, low libido and vaginal dryness, trouble sleeping and weight gain around the midsection are common during perimenopause, as are anxiety and depression. Some women also experience joint and muscle aches, brain fog, heart palpitations and dry eyes, hair and skin. “It can be completely unpredictable, and you never know from day-to-day how you will feel,” Adams said.
Specific symptoms frequently align with a person’s medical history, Adams said. For example, someone who has experienced depression or insomnia in their 20s or 30s is more likely to again during perimenopause.
Symptoms can range in severity — some women can hardly function, while others skate by without noticing any major changes. For many, Adams said, symptoms start mild and progress as menopause gets closer, with periods growing more and more infrequent until they stop.
There’s no specific test to diagnose it
There’s no lab test to diagnose perimenopause, said Venuti, because hormones fluctuate so much and so frequently during this phase — plus, lab numbers don’t necessarily correlate to the symptoms a person manifests, and it’s more important for a provider to know the latter to actually help someone manage symptoms.
“I could draw hormone levels every week, and they’d be all over the place,” Adams said. “They don’t tell me anything symptoms aren’t telling me.”
That said: With no clear path to diagnosis, and because perimenopause shares many symptoms with various health conditions, providers often want to run tests to rule out other causes. For example, if a 42-year-old woman complained of fatigue, hair loss and depression, Barbieri said, she would test for thyroid dysfunction and low iron or vitamin B12.
Once other health conditions are ruled out, providers may proceed with treating symptoms. “We often try treatment and see if it works,” Venuti said.
The right treatment can be life-changing
Because perimenopause is a natural, age-related transition, Barbieri said, the primary focus is symptom management. For women who also want contraception, Venuti said the birth-control pill can be helpful for stabilizing hormones and decreasing problematic symptoms.
Hormone therapy — lower doses of estrogen and progesterone, often delivered through a skin patch or taken as a pill — is another effective option, especially during later perimenopause (though, if you’re still getting a period, Venuti said it’s also important to consider contraception).
Studies have linked hormone therapy with an increased breast cancer risk and other health issues, which made many health care providers stop prescribing it to anyone. But the reality is far more nuanced; while hormone therapy may not be recommended for certain people (including those with a history of breast cancer), it might be considered safer for others, especially those who are at the beginning of their menopause transition, as the risks rise with age. Barbieri said the absence of estrogen can also increase the risk of cardiovascular disease and bone loss. “There are risks and benefits to using a certain therapy or not using it, so conversation with a health care provider is a must for every woman in this age category,” Barbieri said.
Along with medication, lifestyle changes — prioritizing sleep, exercise, nutrition and stress management, Barbieri said — can help mitigate perimenopause symptoms. Providers can also prescribe additional medications for lingering concerns. For example, Barbieri said she prescribes antidepressants for continued mood problems.
Finding the right combination can take time, but treatment is often effective. After seeing several OB/GYNs, Clark found one who believed she was going through perimenopause. She prescribed progesterone and a nonhormonal medication for libido and vaginal dryness, and Clark said she “feels like a new person.”
If you’re experiencing symptoms that are affecting your well-being, Venuti recommended talking to an OB/GYN who is interested in and experienced with perimenopause. You can also find a physician who’s certified by the Menopause Society.
“Perimenopause is a time when people need to partner with a good, experienced clinician,” Adams said. “It’s totally manageable and treatable, and suffering isn’t required to go through it.”
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